DENTAL TECHNOLOGY TRAINING AND CERTIFICATION

The National Association of Dental Laboratories (NADL) is committed to upholding and advancing the commercial dental laboratory industry. This organization emphasizes the following information ¹:

In 46 states, there are no laws to set minimum qualifications for performance of dental technology or the operation of a dental laboratory. However, several states are moving forward with legislative proposals on “mandated technician certification.” The American Dental Association (ADA) Council on Dental Practice voted in 2005 at the NADL’s request to remove some policy language that was an obstacle to laboratory regulation/technician licensure through certification at the state level.² Technicians and laboratories that become certified do so as evidence of their commitment to maintaining professional standards in dental technology. There are approximately 52,000 individual dental laboratory technicians in the United States. Because technicians are not required to be registered or licensed in most states, tracking has to come from various government and private sources.

In 2002, 25 programs in dental laboratory technology were approved (accredited) by the Commission on Dental Accreditation in conjunction with the ADA.

The National Board for Certification, an independent board established by the NADL, offers voluntary certification in dental laboratory technology. Certification can be obtained in five specialty areas: crowns and bridges, ceramics, partial dentures, complete dentures, and orthodontic appliances. Certification is required in the states of Kentucky, Texas, and South Carolina. The standards and requirements for certification do not vary across state lines. A certified dental technician (CDT) tested in New England must demonstrate the same competencies as a CDT tested on the Pacific coast.

To qualify for certification, technicians must have a 2-year dental technology degree or at least 5 years’ experience in dental technology and must pass written and practical examinations. To maintain certification, they must document at least 12 hours of continuing education annually, including study of infection control (specific procedures designed to control the spread of disease agents). The requirements for a certified dental laboratory include having a Certified Dental Technician (CDT) present to supervise each department in the specialty, in which they and the laboratory are certified, to ensure that proper safety and production practices are followed. Certification must be renewed annually.^*

Technicians who maintain their certification must take 12 hours of continuing education each year, including a required hour in OSHA compliant infection control procedures.

The first CDTs were tested in 1958. Today the National Board for Certification tests more than 1200 technicians annually. In 1978, the current standards for laboratory certification were adopted; today there are more than 400 certified dental laboratories.²

In 2004, the U.S. dental laboratory industry produced approximately $5 billion in sales. The number of dental laboratories in the United States is about 12,000.

MUTUAL RESPONSIBILITIES

Good communication is the key to the technical success of the dental team ³^–⁵ This requires a close working relationship between the dentist and laboratory technician. Anticipating satisfactory results is unrealistic if the dentist does not have a reasonable amount of experience with, and a thorough understanding of, dental laboratory procedures. Active participation in the technical procedures by the dentist is paramount, and clinicians who take the time to develop an in-depth understanding of laboratory work make better clinical decisions because of their understanding of applicable technical and material science limitations. Only then can a dentist select the best compromise between technical restrictions, on the one hand, and biologic factors and esthetic needs, on the other. Similarly, if the technician does not appreciate and respect the clinical demands or the treatment rationale of the dentist, the results will be less than satisfactory (Fig. 16-2). The dentist can earn this respect by being prepared to meet personal responsibilities, by listening carefully to technical advice rendered, and by actively participating in the technical decision-making process.

Fig. 16-2 It is often difficult for the technician to appreciate soft tissue contours and embrasure form. These substructures were not fabricated properly—the metal porcelain junction was placed too far facially (arrows). Unless corrected during clinical evaluation, metal would be visible and detract from the appearance of the prosthesis.

Surveys ⁶^–⁸ of fixed prosthodontic laboratories reveal that dentists delegate a significant proportion of their responsibilities. The technicians surveyed were often dissatisfied with the quality of work received; complaints included insufficient information being included in the work authorization, the submission of deficient impressions, and inadequate occlusal records. Such surveys highlight significant problems in dentist-technician communication. In other studies and opinions concerning dentist-technician interaction, whether written by dentists or technicians, the authors emphasized that better patient care is achievable only by better patient care communication.⁹

The ADA has issued guidelines to improve the relationship between dentist and technicians.¹⁰ They are reprinted here:

Working relationships between dentists and dental laboratories: The current high standard of prosthetic dental care is directly related to, and remains dependent upon, mutual respect within the dental team for the abilities and contributions of each member. The following guidelines are designed to foster good relations between dental laboratories, dental laboratory technicians and the dental profession. Applicable laws shall take precedence if they are inconsistent with any of the following guidelines.

The Dentist

1. The dentist should provide written instructions to the laboratory or dental technician. The written instructions should detail the work which is to be performed, describe the materials which are to be used, and be written in a clear and understandable fashion. A duplicate copy of the written instructions should be retained for an appropriate time as may be required by law.

2. The dentist should provide the laboratory technician with accurate impressions, casts, occlusal registrations and/or mounted casts. Materials submitted should be identified.

3. The dentist should identify, as appropriate, the crown margins, post palatal seal, denture borders, any areas to be relieved, and design of the removable partial dentures on all cases.

4. The dentist should furnish instruction regarding preferred materials, coloration, [and] description of prosthetic tooth/teeth to be utilized for fixed or removable prostheses, which may include, but [is] not limited to, a written description, photograph, drawing, or shade button.

5. The dentist should provide verbal or written approval to proceed with a laboratory procedure, or make any appropriate change(s) to the written instructions as the dentist deems necessary, when notified by a laboratory/dental technician that a case may have a questionable area with respect to paragraphs 2–4.

6. The dentist should clean and disinfect all items according to current infection control standards prior to sending them to the laboratory technician. All prostheses and other materials that are forwarded to the laboratory/technician should be prepared for transport, utilizing an appropriate container and packaged adequately to prevent damage and maintain accuracy.

7. The dentist should return all casts, registration, and prostheses/appliances to the laboratory/technician if a prosthesis/appliance does not fit properly or if a shade selection is incorrect.

The Laboratory Technician

1. The laboratory technician should custom manufacture dental prostheses/appliances which follow the guidelines set forth in the written instructions provided by the dentist and should fit properly on the casts and mounting provided by the dentist. Original written instructions should be retained for a period of time as may be required by law. When a laboratory provides custom-printed written instruction forms to a dentist, the laboratory document should include the name of the laboratory and its address, provide ample space for the doctor’s written instruction, areas to indicate the desired delivery date, the patient’s name, a location for the doctor to provide his/her name and address, as well as to designate a site for the doctor to provide a signature. The form should also allow for other information which the laboratory may deem pertinent or which may be mandated by law.

2. The laboratory should return the case to the dentist to check the mounting if there is any question of its accuracy or of the bite registration furnished by the dentist.

3. The laboratory/technician should match the shade which was described in the original written instructions.

4. The laboratory/technician should notify the dentist within two (2) working days after receipt of the case, if there is a reason for not proceeding with the work. Any changes or additions to the written instructions must be agreed to by the dentist and must be initialed by authorized laboratory personnel. A record of any changes shall be sent to the dentist upon completion of the case.

5. After acceptance of the written instructions, the laboratory/technician should custom manufacture and return the prostheses/appliances in a timely manner in accordance with the customary manner and with consideration of the doctor’s request. If written instructions are not accepted, the laboratory/technician should return the work in a timely manner and include a reason for the denial.

6. The laboratory should follow current infection control standards with respect to the personal protective equipment and disinfection of prostheses/appliances and materials. All materials should be checked for breakage and immediately reported if found.

7. The laboratory/technician should inform the dentist of the materials present in the case and may suggest methods on how to properly handle and adjust these materials.

8. The laboratory/technician should clean and disinfect all incoming items from the dentist’s office; e.g., impressions, occlusal registrations, prostheses, etc., according to current infection control standards, placed in an appropriate container, packed properly to prevent damage, and transported.

9. The laboratory/technician should inform the dentist of any subcontracting laboratory/technician employed for preparation of the case. The laboratory/technician should furnish a written order to the dental laboratory which has been engaged to perform some or all of the services on the original written instructions.

10. The laboratory/technician should not bill the patient directly unless permitted by the applicable law. The laboratory should not discuss or divulge any business arrangements between the dentist and the laboratory with the patient.

RESPONSIBILITIES OF THE DENTIST

The dentist has the overall responsibility for the treatment rendered. Delegating many procedures to auxiliary personnel is possible if all the necessary information is provided to enable them to deliver high-quality service. However, errors such as insufficient tooth reduction, uncertainty about the location of tooth preparation margins, improper interocclusal records and articulations, and ambiguity in communicating the desired shades for esthetic restorations to the technician hamper this responsibility.

Infection Control

The U.S. Department of Health and Human Services ¹¹ and the ADA¹² have issued guidelines about the disinfection and handling of impressions and other material transferred from the dental office to the dental laboratory. Applicable guidelines are detailed in Chapter 14. Strict adherence to infection control guidelines cannot be overemphasized, because the potential for infection of dental laboratory personnel exists. In a 1990 sample,¹³ of all materials sent from dental offices to dental laboratories, 67% were contaminated. Results from a more recent questionnaire submitted to dental laboratories suggest that technicians believed in less than 60% of the cases that materials had been appropriately disinfected before being submitted to the laboratory.⁸